case report thoracic endovascular aortic repair in a...

Case ReportThoracic Endovascular Aortic Repair in a Patient with MobileAortic Thrombosis

Graham M. Lohrmann1 and Ferande Peters2

1 Chris Hani Baragwanath Academic Hospital, Old Potchefstroom Road, Soweto, Johannesburg 2013, South Africa2 Flora Clinic, William Nicol Drive, Floracliffe, Johannesburg 1709, South Africa

Correspondence should be addressed to Ferande Peters; [email protected]

Received 30 November 2013; Accepted 1 January 2014; Published 6 February 2014

Academic Editors: C. Gonzalez-Juanatey, A. Silvestro, and A. Zirlik

Copyright © 2014 G. M. Lohrmann and F. Peters. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

A 58-year-old female presented with acute arterial insufficiency to her left leg. Following cardiovascular evaluation usingmultimodality imaging, it was discovered that she had mobile thoracic thrombi overlying a normal descending thoracic aortawhich had also caused a splenic infarction. This patient was treated with unfractionated heparin for three days and underwentsubsequent thoracic endovascular aortic repair (TEVAR) uneventfully with no subsequent complications at one-year followup.Thiscase highlights the diagnostic and therapeutic challenges in treating patients with this uncommon challenging clinical scenario.

1. Case Scenario

A 58-year-old female presented with symptoms and signscompatible with an acutely threatened left leg. Her historyrevealed that she had no preexisting significant cardiovas-cular symptoms of note and she had no risk factors foratherosclerosis. There was no family history to suggest anyhereditary thrombotic disorders.

A computed tomography angiogram (CTA) was per-formed which confirmed abrupt cutoff of the left mid- todistal tibial artery in the left leg, as well as a recanalizedsplenic infarction. In addition, as part of her workup beforereferral, a CTA of the thoracic aorta was performed whichrevealed a linear filling defect measuring 8 cm which wasinterpreted as an aortic dissection with an intimal flap(Figures 1(a) and 1(b)).

The patient was transferred for cardiological assessmentwhere a transthoracic echocardiography revealed hyperten-sive heart disease with a normal ejection fraction and milddiastolic dysfunction. A transesophageal echo (TEE) revealeda large mobile aortic thrombus in the proximal descendingaorta distal to the subclavian artery origin accompanied bytwo other distal mobile thrombi (Figures 2 and 3, see Videos1, 2, and 3 in Supplementary material available online athttp://dx.doi.org/10.1155/2014/302346.). There were no overt

features of either a penetrating aortic ulcer or aortic dis-section. The laboratory workup for hereditary and acquiredprothrombotic disorders, including vasculitis, was normal.The patient was treated for three days with an intravenousunfractionated heparin infusion and, following extensivecardiothoracic and vascular consultation, thoracic endovas-cular aortic repair (TEVAR) was successfully performed(Figure 4), whilst the leg ischaemia resolved spontaneouslyon anticoagulation alone. Following initiation of lifelongwarfarin therapy, a follow-up TEE six months later revealedno thrombus or subsequent complications.

2. Discussion

Thoracic aortic mobile thrombus (TAMT) is generallydefined as mobile thrombus occurring in a nonaneurysmalthoracic aorta such that embolism is thought likely to occurfrom separation of the thrombus body from its base.

It is a relatively rare clinical entity with few case reportsand series published since the regular use of CTA andTEE was introduced in locating arterial embolic sources.According to a large postmortem study of 10, 671 autopsies byMachleder and associates [1], the incidence of intraluminalmural thrombosis in nonaneurysmal thoracic aortas was0.09%, with no distinction between mobile and adherent

Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2014, Article ID 302346, 4 pageshttp://dx.doi.org/10.1155/2014/302346

2 Case Reports in Vascular Medicine

(a) (b)

Figure 1: Axial and sagittal images of a computed tomography angiogram demonstrating a serpiginous filling defect in the descendingthoracic aorta.

Figure 2: Two-dimensional transesophageal echocardiogram (2DTEE) X-plane images demonstrating two aortic thrombi.

Figure 3: Three-dimensional transesophageal echocardiogram (3DTEE) demonstrating two thrombi in cross-section.

thrombi. Tunick et al., in their study of 122 patients having aTEE for suspected cardioembolic stroke, reported an aorticatheroma incidence of 27%, of which 30% had overlyingTAMT [2].

TAMT is most commonly identified during a workupfor possible cardioembolic clinical presentations on eitherCT/echocardiography. Commonly encountered cardioem-bolic presentations include stroke [3–6], an acutely threat-ened limb or blue toe syndrome [7, 8], and abdominalischaemic syndromes [3, 9–11], including renal or splenicinfarcts and mesenteric ischaemia. However, a few authorshave reported asymptomatic TAMT following thoracic CTAdone for unrelated reasons, including to rule out pulmonaryemboli or an acute traumatic aortic syndrome [12, 13].

Figure 4: Poststent deployment aortic angiogram demonstratingsuccessful exclusion of the thrombus bulk with a small area ofresidual thrombus at the inferior edge.

The underlying pathogenesis of aortic thrombosis has notbeen well elucidated. The age at presentation varies betweencase series, with a 14-patient case series by Pagni et al. havingan average age of 50.6 years, with no significant predilectionfor either gender [3]. TAMT may develop on an underlyingdiseased aorta due to underlying atheroma, aortic dissection,intimal flap, or aortitis [3, 5, 7, 9, 14]. Occasionally, TAMTmay develop on what appears to be a normal underlyingaorta. In this instance, thrombosis is most commonly due toa prothrombotic state, whether hereditary or acquired [10].In addition, an underlying proinflammatory state associatedwith inflammatory bowel disease or systemic autoimmunecollagen vascular disease such as rheumatoid arthritis hasbeen reported as the underlying cause of thrombosis by Elderet al. [8] and Krishnamoorthy et al. [11], respectively. Despiteexhaustive investigation, no cause could be identified in astrikingly large number of cases [3, 6, 12], as in this case.

The aim of therapy is to abolish the thrombus burdenwhilst ensuring no further embolism occurs. One therapeuticoption is medical therapy alone, by means of anticoagu-lation, for example, using heparin and warfarin, with orwithout antiplatelet therapy, such as aspirin and clopidogrel.

Case Reports in Vascular Medicine 3

The second option is an interventional approach usingadjunctive anticoagulation and either open surgical throm-bectomy or TEVAR. Treatment of this rare entity hasnot been established or tested in case control trials orlarge meta-analyses. Many authors have reported res-olution of clot and no further thromboembolism with anti-coagulation with or without antiplatelet agents alone [3, 4,6–8, 12, 13], while others have also had success with opensurgical thrombectomy and postoperative anticoagulation[3, 6, 9, 10, 14], with the added benefit of addressing theorganised thrombus component which is unlikely to respondto anticoagulation but at a risk of increased perioperativemorbidity and mortality. A number of authors have, on thebasis of trends in the literature, recommended early surgicalover medical therapy. Pagni et al., in their review of 80patients in case series from 1997 to 2010, found the recurrenceor failure rate of open surgical intervention to be 16%, ascompared to 24% for anticoagulation alone [3]. Although thenumbers are small and statistically insignificant, it representsa strong trend favouring surgical treatment. It is noteworthythat the vast majority of case series and reports documentonly symptomatic aortic thrombus, that is, having resulted inembolic disease. The treatment consensus of asymptomaticthoracic aortic mobile thrombus is even more obscured.

Thoracic endovascular aortic repairs (TEVAR) usingendovascularly deployed stents have found themselves intocommon use in treating non-TAMT aortic pathology withlarge studies supporting their use, having reduced earlymorbidity and mortality and equal late mortality comparedwith open surgery, yet at the cost of increased need forreintervention and follow-up [6, 15]. There are however fewcase reports of success with endovascular treatment ofmobileaortic thrombus with exclusion of the aortic thrombus fromthe aortic lumen in the abdominal aorta [6, 16], with evenfewer reporting success with thoracic thrombi [17], that is,TEVAR.

TEVAR was chosen in this case for three reasons. Firstly,it is the authors’ opinion on review of the literature that anti-coagulation therapy alone insufficiently addresses a possibleorganised thrombus component and has a theoretical riskof dissolving the thrombus stalk before the thrombus body,resulting in recurrent thromboembolic disease. Secondly, thepatient was seen as a high risk for open surgery, and thus aless invasive approach seemed appropriate.Thirdly, it was feltthat stent placement could occur successfully above T6 andthus any compromise of the artery ofAdamkiewicz and spinalfunction would be less likely.

3. Conclusion

TAMT is a rare clinical entity usually diagnosed duringcardioembolism workup and is complicated by major clinicalembolic consequences. While there is no consensus on whatconstitutes optimal management, interventional approachesseem to be superior in terms of mortality and recurrence.It is to be borne out in future studies whether TEVARoffers a viable alternative in TAMT as it has in other aorticpathologies.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

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[8] K. Elder, R. Hawi, and F. A. Solaiman, “Inflammatory boweldisease-related thoracic aortic thrombosis,” Southern MedicalJournal, vol. 103, no. 2, pp. 172–174, 2010.

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[10] L. Zhang, S. Hollensead, and J. C. Parker Jr., “Extensive aorticthromboembolism due to acquired hypercoagulable state: anautopsy case report,” Archives of Pathology and LaboratoryMedicine, vol. 129, no. 2, pp. 247–250, 2005.

[11] V. Krishnamoorthy, K. Bhatt, R. Nicolau, M. Borhani, andD. E. Schwartz, “Transesophageal echocardiography-guidedaortic thrombectomy in a patient with a mobile thoracic aorticthrombus,” Seminars in Cardiothoracic and Vascular Anesthesia,vol. 15, no. 4, pp. 176–178, 2011.

[12] I. Hassan, K. J. Zehr, and W. K. Freeman, “A case of asymp-tomatic thoracic aorta mural thrombi,” The Annals of ThoracicSurgery, vol. 72, no. 5, pp. 1735–1737, 2001.

[13] R. Loffroy, L. Boussel, F. Farhat, and P. Douek, “Isolated floatingthrombus of the thoracic aorta: a rare sign of traumatic aorticinjury managed with anticoagulant therapy,” The Annals ofThoracic Surgery, vol. 84, no. 5, p. 1766, 2007.

[14] M.H.Goldman, B. Akl, S.Mafi, and L. Pastore, “Granulomatousaortitis presenting as an acute myocardial infarction in Crohn’sdisease,” Circulation, vol. 102, no. 24, pp. 3023–3024, 2000.

[15] H. J. Patel, V. Sood, D. M. Williams, N. L. Dasika, A. C. Diener,and G. M. Deeb, “Late outcomes with repair of penetratingthoracic aortic ulcers: the merits of an endovascular approach,”The Annals of Thoracic Surgery, vol. 94, no. 2, pp. 516–523, 2012.

4 Case Reports in Vascular Medicine

[16] W. J. Metsemakers, J. Duchateau, F. Vanhoenacker, Y. Tiele-mans, and J. de Leersnyder, “Floating aortic thrombus: theendovascular approach,” Acta Chirurgica Belgica, vol. 113, no. 1,pp. 47–50, 2013.

[17] T. Martens, I. van Herzeele, B. Jacobs, F. de Ryck, C. Randon,and F. Vermassen, “Treatment of symptomatic mobile aorticthrombus,” Acta Chirurgica Belgica, vol. 110, no. 3, pp. 361–364,2010.

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